Medicine getting up close and personal

Preventive health checks are not all they are cracked up to be. Irrespective of how expensive or comprehensive the package that you’ve opted for is, you have to deal with smiling, clueless nurses, disinterested doctors, being misdirected to wrong examination rooms, waiting your turn outside diagnostic centres, tracking doctors who said they’d get back to you but didn’t, and finally, dealing with apologetic staff who inadvertently misplace one or more of your reports.

And if you take the trouble of matching the final summary with the many diagnostic reports handed back to you, you’ll be on for some surprises. I know of a woman who was told her uterus was “normal” after she had undergone a hysterectomy (surgical removal of the uterus) and a man being told his prostate was “healthy” even when the PSA (prostate specific antigen) readings were shooting through the roof.

The cause for both goof-ups was easy enough to guess -- both patients were young and the doctors doing the preventable health check-up did not expect them to have problems associated with people aged 45 and over.

2013 may well be the year of the death of the preventive health examination as we know it. “The physical”, which is the staple of medical diagnosis the world over, does not reduce disease or death, either overall or from heart disease and cancers, reported the British Medical Journal (BMJ) late last year. What it did do was increase new diagnosis of underlying chronic diseases, like diabetes or high blood pressure, found a review and meta-analysis of 16 randomised trials. This means that while it added to referrals and got more people in the sphere of disease management, it made no difference to overall outcomes.

The review triggered a debate and became among the top-five most viewed articles in 2013 on Medscape, a medical resource for medical students and professionals. The conclusion was that “the physical” did little to prevent disease and death.

The BMJ study was prompted by the general health exam of a 58-year-old woman. The competent junior doctor who examined her did everything needed with clinical efficiency -- HPI (history of present illness), PMH (past medical history), PSH (past surgical history), meds, allergies... The last finding in the his 18-item review of systems was painless vaginal bleeding for three months. After a meticulous physical examination, he recommended a women’s health screening at her next appointment along with a proper examination and evaluation at that time.

Despite the unexplained bleeding, he did not consider doing a pelvic examination.

“What is the number-one concern regarding this bleeding?” he was asked. “Cancer,” he responded correctly. “So why not perform a better evaluation of this patient’s cancer risk right now?” “I guess I thought that the patient was here for a general exam, so I focused on that. That form is really long.”

That’s exactly the problem with a physical exam. It involves multiple departments, there’s little ownership, it’s impersonal as the doctors are not likely to see the patient again, and its mind-numbingly tedious. Since there are at least a dozen people involved in doing and analysing a general health check, few give it the same degree of attention as they would to a patient who walks into their clinic. They all assume that if something is missed, someone else will pick it up. Often, someone does, but symptoms are equally often missed.

The problem lies in its structure, which needs an overhaul. We live in an age of personalised medicine where diagnostic procedures and drug therapies should be tailored to maximise their impact on individuals. Yet, the general health examination runs counter to this, with the same questions being asked and tests being done for 20 and 50 year olds.

The general physical examination should focus on specific indicators of disease for individuals, and not broad reviews for potential disease. The physical would work best if you get a general physician to do an extensive review and then prescribe the relevant tests and scans.

This does not mean that diagnostic tests should become the mainstay of physical examination. Medical imaging is expensive and overexposure carries some risk. Radiation in the form of X-rays and CT-scans is many times greater than background radiation, which is why other non-invasive imaging techniques that do not involve the use of X-rays, such as MRIs and ultrasounds, are increasingly being used.

Advances in imaging should lead to better care, prompt diagnosis and improved outcomes, but this can only happen if the physicians listens to the patient instead of worrying about filling forms and ticking boxes.